Rapid implementation of telepharmacy service to improve patient‐centric care and multidisciplinary collaboration across hospitals in a COVID era: A cross‐sectional qualitative study

Abstract Background and Aim The COVID‐19 pandemic forced healthcare systems to apply new technology‐based solutions. The main objective of our study was to describe the conceptual model for rapid implementation of telepharmacy service and the main steps that should be considered. Method In response to a limited number of on‐site clinical pharmacy specialists and a lack of technology infrastructure, a cross‐sectional telepharmacy program was established to support major teaching hospitals. A store and forward model of teleconsultation was employed using WhatsApp messenger to cover various aspects of multidisciplinary collaboration in COVID‐19 management. All identifiable personal information was removed from all exchanged messages of collaborative consultations. The thematic analysis of consultations was performed to extract the main themes and subthemes that should be considered for designing future telepharmacy systems. Results Through telepharmacy service, 600 intensive care unit teleconsultations for COVID‐19 cases were conducted in the residence center and nonresidence centers. In total, 1200 messages were exchanged between specialists in 3 months. The average time taken to respond to a message was 1.30 h. Thematic analysis revealed four main concepts and 15 subconcepts that should be considered in telepharmacy consultations for COVID‐19 management. Based on the extracted themes, a conceptual model for developing a telepharmacy program was devised. Conclusion The results showed that by utilizing telehealth, clinical pharmacists could cover critically ill patients who need pharmacotherapy counseling through interdisciplinary collaboration. Moreover, the main features of our service that are represented through this survey can be employed by other researchers for developing telepharmacy services.


| BACKGROUND
COVID-19 is a complex multisystem disorder, severe cases of which may require intensive care unit (ICU) admission. The rapid increase in COVID-19 cases led to significant demand for hospital admissions and intensive care. 1,2 During the pandemic, healthcare professionals utilized different solutions to ensure the optimal management of infected patients with the virus and those at risk of the infection. 3 To improve the efficiency of patient care, interprofessional and multidisciplinary collaboration across hospitals and health systems is augmented during a pandemic. 4 Due to the high ambiguity of inpatient treatment, clinical pharmacists have a crucial role in healthcare team practices 5 as active members of the interdisciplinary critical care team. 6 During the COVID-19 pandemic, several drugs were used in the context of clinical trials or for off-label use; and many physicians were unfamiliar with them. Thus, patients required comprehensive medical management with clinical pharmacist consultation to guide physicians and ensure the safe and effective usage of drugs. Pharmacists' participation in clinical decision-making facilitates COVID-19 management according to the last clinical protocols. 7 The lack of critical care pharmacists and intensivists was the greatest obstacle to providing appropriate pharmacotherapeutic care in critical care units. In addition, interactions between specialists in clinical rounds have been restricted due to close contacts limitation during the pandemic. 2 To overcome the mentioned obstacles, 8 telemedicine-based, and innovative approaches were taken by researchers to minimize these barriers to interprofessional collaboration. 9 It was an opportunity to apply technology at a speed that would not be possible at any other time to reduce the risk of exposure. 10 Telepharmacy is one of the telemedicine aspects that can provide near real-time consultation around the country and meet the need to access high-quality and up-to-date evidence. 11,12 COVID-19 has also resulted in overloaded, ever-changing information. Nearly 8000 articles were published in the first 4 months of the outbreak. This abundance of information contributes to variability in practice, confusion, and decision fatigue which can affect the ability of healthcare providers to provide optimal patient care. 13,14 The information overload and the complexity of COVID-19 cases made it even more essential to work and decide together to serve patients.
As the subject of medicine is so broad, the collaboration between multidisciplinary team (MDT) members provides a multidimensional thinking pattern; this can enhance ease of decision-making and improve patient safety. 15 The present pandemic provided an opportunity to feel the value of each member of the MDT.
Using telepharmacy in the COVID-19 pandemic can improve consultation with other healthcare providers and decrease adverse drug effects and interactions. 16 Thus, clinical pharmacists can expand their services to more patients in different centers. Telepharmacy can eliminate the need for on-site pharmacists in a clinical setting for consultation. 12 However, it needs a platform to connect healthcare providers with pharmacists to share their information and communicate with others. A wide variety of free chat-based software is currently available (like WhatsApp, Viber, Google Hangouts, Zoom, Telegram, and Skype) with good camera quality and a good internet connection. 17 They allow instant sharing of the necessary information between healthcare professionals. Messaging applications like WhatsApp Messenger are using end-to-end encryption that enhances the security of shared information. 18 Due to WhatsApp messenger's popularity among healthcare providers and freely available for most smartphones with different operating systems, it was selected as an appropriate tool to implement telepharmacy service as soon as possible.
The current pandemic has forced individuals and healthcare systems to review feasible and desirable models to manage this crisis and changed previous practices. Our main goal is to quickly implement a free online consultation service to access pharmaceutical care in the difficult circumstances of the pandemic. The main aim of our study was to describe an easy and fast solution to improve interprofessional collaboration between different specialists in hospitals for the management of critically ill patients through telemedicine. Other objectives of our study were to describe a conceptual model for developing telepharmacy services to expand clinical pharmacy consultation in a time of crisis through qualitative analysis.

| METHODS
Following the global outbreak of COVID-19 and two deaths in Qom city due to COVID infection, the Iranian Ministry of Health officially announced the COVID-19 outbreak in the country. Over a short period (February 19 to March 11), Iran became one of the most affected countries in the world. The pharmacotherapeutic care of these patients who required intensive care was complex. 19 As COVID-19 spreads across Tehran, on February 18, 2020, in response to a limited number of on-site clinical pharmacy specialists, a crosssectional telepharmacy program was established in Shariati and Imam Khomeini hospitals which are the two main teaching hospitals of Tehran University of Medical Sciences. We employed a store-andforward model of teleconsultation using WhatsApp messenger to facilitate teamwork collaboration. Store and forward referred to a type of asynchronous telemedicine service in which clinical data were collected, captured, and transformed electronically. Store-andforward services provide access to data after it has been collected outside of real-time patient interaction. 20,21 CAT Scans, magnetic resonance imaging, X-rays, photos, videos, and text-based patient data are gathered and sent to clinical pharmacists using WhatsApp after de-identifying personal information. 22,23 The method and results were reported according to the Consolidated criteria for reporting qualitative research checklist for qualitative studies.

| Inclusion and exclusion criteria
Briefly, participants were physicians treating COVID-19 cases that were admitted to the ICU. All of them were employed by the teaching hospitals of Tehran University of Medical Sciences. Participants were included in this study if they had a valid WhatsApp account and if they agreed to use WhatsApp for consultations. According to our protocol, if their patients need a consultation with a clinical pharmacist, they use WhatsApp to consult clinical pharmacists. All COVID-19 patients who needed teleconsultations were eligible for our study and included in the study when the clinical pharmacist received the first message of consultation request. We analyzed the data regarding these consultations. Physician's participation was also voluntary and anonymity was guaranteed. In this study, patients whose consultations were related to other diseases and patients afflicted with problems involving multiple services except intensive care were excluded from the study. Eligible patients who were treated by an intensivist in consultation with a clinical pharmacist at the bedside via WhatsApp platform were evaluated in the study.

| Designing telepharmacy service
Due to busy working conditions, lack of clinical pharmacy specialists, and the need for transportation, real-time consultations could not be performed at the patient's bedside during the COVID-19 pandemic.
Following these circumstances, consultations via WhatsApp emerged naturally due to the overcrowding of ICU patients.

| WhatsApp platform
WhatsApp© (WhatsApp Inc.) is an instant messaging application for smartphones using the Internet connection to send different types of data, including text messages, images, video, user location, and audio messages. We utilized the WhatsApp platform for sharing information due to its popularity, free-of-charge accessibility, and ease of use. This selection was made for the rapid implementation of the program during the COVID pandemic and lack of clinical resources condition.
Nevertheless, any social networking platform can be used according to the experts' demands as far as confidentiality could be maintained. The moment of sending the consultation request was recorded as the beginning of the patient's consultation period. Accordingly, the response time to the WhatsApp request was assumed as the consultation response time.

| Analysis of results
After 3 months of conducting the telepharmacy program in our clinical pharmacy service, the content of the consultations was converted to Word documents for qualitative analysis. A thematic analysis 26 was applied to determine the main domains, categories, and information flow of the telepharmacy service. Messages were examined in the context of medication advice that was posted. The process of identifying themes was conducted iteratively according to Braun and Clarke's 26 approach. 27 This made it possible to identify the most common issues that were discussed through consultation. Each message was read several times to generate a list of potential themes.
Themes and sub-themes were classified to form the conceptual framework of telepharmacy service.

| Service description
The general model of implemented telepharmacy service in our center and the interaction between MDT members are described in After careful evaluation of the cases and reviewing the latest information, the appropriate medication management considering the patient's condition (green arrows) will be shared by the clinical pharmacist. These messages included not only textbased messages but also image-based and audio messages.
Image-based messages included radiology findings, lab data, and patient medication lists. In the following, the models and frameworks were obtained through consultations analysis were represented. The themes and subthemes in Figure 2 can be used as a conceptual model to determine the characteristics of a systematic remote drug consultation system.

|
These extracted themes showed that telepharmacy consultations covered a wide variety of problems, including antimicrobial management, individualized therapeutic adjustment, anticoagulation, nutrition support, pain, agitation, and delirium management. Other subthemes covered the safety and effectiveness of drugs and medication plans. The content of the advice exchanged in the form of messages between healthcare providers is given in Table 1 as examples of each category for better understanding.

| Sharing information and decision-making process in the telepharmacy program
As we showed in the proposed model of applying telemedicine, pharmacists can play a more active role in increasing access to the latest evidence and protocols for the medical care team. Based on conducted consultation, we proposed a model in Figure 3 to represent a set of tasks that occurred during telepharmacy service establishment. Through this model, we can find out how clinical pharmacists can communicate with several centers through teleconsultation. The information in the proposed model refers to any types of patients' clinical data that are collected during pharmacotherapeutic care (Table 2). Additionally, scientific information in the form of protocols and practice guidelines can be shared between several centers. F I G U R E 1 The telepharmacy consultation model (In this model, physicians and nurses from two different hospitals [red and blue teams]) can share clinical information and patient records (yellow arrows) with a clinical pharmacist through telemedicine tools. After careful evaluation of the case and reviewing the latest information, the appropriate medication management considering the patient's condition (green arrows) will be shared by the clinical pharmacist, and the patient benefits from it

| DISCUSSION
The COVID-19 pandemic has affected the world in many ways and forced health systems to rapidly adopt telemedicine-based solutions to improve patient-centered care. Through this study, we established telepharmacy care and suggested a conceptual model addressing the overloaded pharmacy services during the COVID-19 pandemic. Our research showed that the telepharmacy service was convenient, and it can provide high-quality, rapid, and time-saving consultations with other healthcare providers.
The proposed model could offer a feasible and cost-effective way to expand the clinical pharmacists' services, but it might encounter a few obstacles. As the main objective of our study was to provide a model and determine the main components of telepharmacy service in the context of teleconsultation for implementing a third-party system in further study, we discuss some of the possible challenges and benefits of our proposed model.
Our survey showed that telepharmacy service has three main components: (1) a pharmacist who is the key member in a telemedicine service who provides consulting services to applicants, (2) a social media application or an electronic chat-based software platform that provides sharing information, the possibility of conversation and consultation between experts, and (3) the specialists who seek medical consult.
Though pharmacists are recognized as essential members of the critical care team, the pharmacist-to-patient ratio is even low in developed countries. 6,28 Thus, a telepharmacy service is implemented to provide this opportunity for clinical pharmacy service to support more patients with extra work in special situations like a pandemic.
Telemedicine services have become an integral part of medicine. 9 Evidence has shown that social media has a pivotal role in teleconsultations. 17 In this study, WhatsApp messenger was selected for rapid implementation. In this study, WhatsApp messenger, a freeof-charge messaging platform that can provide sharing instant messages with pictures and videos, was selected based on our objectives. 25,29 However, the suggested model and determining The security of personal health data transmitted electronically is always a concern of telehealth programs. Since there is no ready infrastructure for teleconsultation and the pandemic forced us to act rapidly, we used WhatsApp messenger, which uses end-to-end encryption that enhances the security of shared information.
For proper patient care, those directly involved in patient care must be able to share patient information to coordinate care, and this is not against the principles of confidentiality. 24,30 In general, medical

CONFLICTS OF INTERESTS
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author.

ETHICS STATEMENT
The authors affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.